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The late Holocene Bonneville landslide, a 15.5 km2 rockslide-debris avalanche, descended 1000 m from the north side of the Columbia River Gorge and dammed the Columbia River where it bisects the Cascade Range of Oregon and Washington, USA. The landslide, inundation, and overtopping created persistent geomorphic, ecologic, and cultural consequences to the river corridor, reported by Indigenous narratives and explorer accounts, as well as scientists and engineers. From new dendrochronology and radiocarbon dating of three trees killed by the landslide, one entrained and buried by the landslide and two killed by rising water in the impounded Columbia River upstream of the blockage, we find (1) the two drowned trees and the buried tree died the same year, and (2) the age of tree death, and hence the landslide (determined by combined results of nine radiocarbon analyses of samples from the three trees), falls within AD 1421–1455 (3σ confidence interval). This result provides temporal context for the tremendous physical, ecological, and cultural effects of the landslide, as well as possible triggering mechanisms. The age precludes the last Cascadia Subduction Zone earthquake of AD 1700 as a landslide trigger, but not earlier subduction zone or local crustal earthquakes.
The objective was to examine the prospective relationship between folate and vitamin B12 (B12) status and incident depressive symptoms in a representative cohort of community-dwelling older people. This was a longitudinal study utilising the Irish Longitudinal Study on Aging (n =3,849 aged ≥50 years) and investigated the relationship between blood plasma folate and B12 levels at baseline (wave 1) and incident depressive symptoms at 2 and 4 years (waves 2 and 3). Participants with depression at wave 1 were excluded. A score ≥9 on the Center for Epidemiologic Studies Depression Scale-8 at wave 2 or 3 was indicative of incident depressive symptoms. Plasma B12 and folate concentrations were determined by microbiological assay. B12 status profiles (pmol/l) were defined as: <185, deficient-low; 185 - <258, low normal; >258 - 601, normal and >601 high. Folate status profiles (nmol/l) were defined as: ≤10.0, deficient-low; >10 - 23.0, low normal; >23.0 - 45.0, normal; >45.0, high. Logistic regression models reporting odds ratios were used to analyse the longitudinal association of B-vitamin categories with incident depression. Both B12 and folate plasma concentrations were lower in the group with incident depressive symptoms vs. non depressed (folate: 21.4 vs. 25.1 nmol/L; P=0.0003); (B12: 315.7 vs. 335.9 pmol/L; P=0.0148). Regression models demonstrated that participants with deficient-low B12 status at baseline had a significantly higher likelihood of incident depression four years later (odds ratio 1.51, 95% CI 1.01-2.27, P=0.043). This finding remained robust after controlling for relevant covariates including physical activity, chronic disease burden, vitamin D status. cardiovascular disease and antidepressant use. No associations of folate status with incident depression were observed. Older adults with deficient-low B12 status had a 51% increased likelihood of developing depressive symptoms over 4 years. Given the high rates of B12 deficiency, these findings are important and highlight the need to further explore the low cost benefits of optimising vitamin B12 status for depression in older adults.
The definition of combined approaches is broad. This can include multiple portals to the same or different region in the skull base. The “pull-through technique is a versatile, dual-keyhole approach developed to attach tumors that extend between the temporal and occipital poles. This approach is complex, as it entails a knowledge of the intricate anatomy and eloquent cortical and subcortical structures in this region. This combined approach is tailed to minimize peripheral brain damage while providing a direct route to the pathology. This chapter discusses the indications, the anatomy, the patient selection, and the surgical nuances of this approach.
The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.
We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.
Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.
To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.
The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
Early assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients.
Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health & Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers.
A retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel.
41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%.
The PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended.
This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.
Community forestry has long been regarded as a way to achieve the sustainable management of forest and tree resources while maximizing benefits for those responsible for the custodianship of natural resources. Throughout much of the developing world, forests and the lands they occupy have been increasingly ceded to the management and control of Indigenous peoples and local communities. In the post-conflict environment of Liberia, community forestry has been identified as a means of maximizing the engagement of local communities in forest management initiatives. Liberia’s recent comprehensive National Forestry Policy is an important step forward in this process. The new legislative framework makes it clear that a major reorientation of the forestry sector is required if it is to successfully address the economic challenges facing the country. These challenges concern the need to substantially improve forest governance and to ensure that the forest sector contributes more effectively to the alleviation of poverty and livelihood improvement. While, on paper, the legal framework for community forestry is robust, implementation is falling short due to conflicts over land and resources that have pervaded the Liberian forestry sector for decades. Increased investment in oil palm expansion, artisanal agriculture and broader government-supported logging activities all threaten the implementation of community forestry. Concomitantly, a fundamental lack of capacity at the community level and at the level of the Forestry Department has curtailed early attempts to operationalize community forestry in the country. In this chapter we explore the evolution and development of community forestry in Liberia, and assess prospects for its future implementation. We provide a clear framework of recommendations to address potential constraints to its success.
The uncertainty surrounding high intakes of folic acid and associations with cognitive decline in older adults with low vitamin B12 status has been an obstacle to mandatory folic acid fortification for many years. We estimated the prevalence of combinations of low/normal/high vitamin B12 and folate status and compared associations with global cognitive function using two approaches, of individuals in a population-based study of those aged ≥50 years in the Republic of Ireland. Cross-sectional data from 3781 men and women from Wave 1 of The Irish Longitudinal Study on Ageing were analysed. Global cognitive function was assessed by the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Prevalence estimates for combinations of vitamin B12 (plasma vitamin B12 < or ≥258 pmol/l) and folate (plasma folate ≤ or >45·3 nmol/l) concentrations were generated. Negative binomial regression models were used to investigate the associations of vitamin B12 and folate status with global cognitive function. Of the participants, 1·5 % (n 51) had low vitamin B12 (<258 pmol/l) and high folate (>45·3 nmol/l) status. Global cognitive performance was not significantly reduced in these individuals when compared with those with normal status for both B-vitamins (n 2433). Those with normal vitamin B12/high folate status (7·6 %) had better cognitive performance (MMSE: incidence rate ratio (IRR) 0·82, 95 % CI 0·68, 0·99; P = 0·043, MoCA: IRR 0·89, 95 % CI 0·80, 0·99; P = 0·025). We demonstrated that high folate status was not associated with lower cognitive scores in older adults with low vitamin B12 status. These findings provide important safety information that could guide fortification policy recommendations in Europe.
Institutionally deprived young children often display distinctive patterns of attachment, classified as insecure/other (INS/OTH), with their adoptive parents. The associations between INS/OTH and developmental trajectories of mental health and neurodevelopmental symptoms were examined. Age 4 attachment status was determined for 97 Romanian adoptees exposed to up to 24 months of deprivation in Romanian orphanages and 49 nondeprived UK adoptees. Autism, inattention/overactivity and disinhibited-social-engagement symptoms, emotional problems, and IQ were measured at 4, 6, 11, and 15 years and in young adulthood. Romanian adoptees with over 6 months deprivation (Rom>6) were more often classified as INS/OTH than UK and Romanian adoptees with less than 6 months deprivation combined. INS/OTH was associated with cognitive impairment at age 4 years. The interaction between deprivation, attachment status, and age for autism spectrum disorder assessment was significant, with greater symptom persistence in Rom>6 INS/OTH(+) than other groups. This effect was reduced when IQ at age 4 was controlled for. Age 4 INS/OTH in Rom>6 was associated with worse autism spectrum disorder outcomes up to two decades later. Its association with cognitive impairment at age 4 is consistent with INS/OTH being an early marker of this negative developmental trajectory, rather than its cause.
In 2017, Public Health England South East Health Protection Team (HPT) were involved in the management of an outbreak of Mycobacterium bovis (the causative agent of bovine tuberculosis) in a pack of working foxhounds. This paper summarises the actions taken by the team in managing the public health aspects of the outbreak, and lessons learned to improve the management of future potential outbreaks. A literature search was conducted to identify relevant publications on M. bovis. Clinical notes from the Public Health England (PHE) health protection database were reviewed and key points extracted. Animal and public health stakeholders involved in the management of the situation provided further evidence through unstructured interviews and personal communications. The PHE South East team initially provided ‘inform and advise’ letters to human contacts whilst awaiting laboratory confirmation to identify the infectious agent. Once M. bovis had been confirmed in the hounds, an in-depth risk assessment was conducted, and contacts were stratified in to risk pools. Eleven out of 20 exposed persons with the greatest risk of exposure were recommended to attend TB screening and one tested positive, but had no evidence of active TB infection. The number of human contacts working with foxhound packs can be large and varied. HPTs should undertake a comprehensive risk assessment of all potential routes of exposure, involve all other relevant stakeholders from an early stage and undertake regular risk assessments. Current guidance should be revised to account for the unique risks to human health posed by exposure to infected working dogs.
In 785 mother–child (50% male) pairs from a longitudinal epidemiological birth cohort, we investigated associations between inflammation-related epigenetic polygenic risk scores (i-ePGS), environmental exposures, cognitive function, and child and adolescent internalizing and externalizing problems. We examined prenatal and postnatal effects. For externalizing problems, one prenatal effect was found: i-ePGS at birth associated with higher externalizing problems (ages 7–15) indirectly through lower cognitive function (age 7). For internalizing problems, we identified two effects. For a prenatal effect, i-ePGS at birth associated with higher internalizing symptoms via continuity in i-ePGS at age 7. For a postnatal effect, higher postnatal adversity exposure (birth through age 7) associated with higher internalizing problems (ages 7–15) via higher i-ePGS (age 7). Hence, externalizing problems were related mainly to prenatal effects involving lower cognitive function, whereas internalizing problems appeared related to both prenatal and postnatal effects. The present study supports a link between i-ePGS and child and adolescent mental health.
Hypertrophic cardiomyopathy has a range of clinical severity in children. Treatment options are limited, mainly on account of small patient size. Disopyramide is a sodium channel blocker with negative inotropic properties that effectively reduces left ventricular outflow tract gradients in adults with hypertrophic cardiomyopathy, but its efficacy in children is uncertain. A retrospective chart review of patients ⩽21 years of age with hypertrophic cardiomyopathy at our institution and treated with disopyramide was performed. Left ventricular outflow tract Doppler gradients before and after disopyramide initiation were compared as the primary outcome measure. Nine patients received disopyramide, with a median age of 5.6 years (range 6 days–12.9 years). The median left ventricular outflow tract Doppler gradient before initiation of disopyramide was 81 mmHg (range 30–132 mmHg); eight patients had post-initiation echocardiograms, in which the median lowest recorded Doppler gradient was 43 mmHg (range 15–100 mmHg), for a median % reduction of 58.2% (p=0.002). With median follow-up of 2.5 years, eight of nine patients were still alive, although disopyramide had been discontinued in six of the nine patients. Reasons for discontinuation included septal myomectomy (four patients), heart transplantation (one patient), and side effects (one patient). Disopyramide was effective for the relief of left ventricular outflow tract obstruction in children with hypertrophic cardiomyopathy, although longer-term data suggest that its efficacy is not sustained. In general, it was well tolerated. Further study in larger patient populations is warranted.
Coastal ecosystems are particularly vulnerable to alien invasions. Regular, standardized, targeted monitoring of coastal areas helps to detect the arrival of non-native species early, identify sites most vulnerable to invasion, and assess potential for further spread. This study quantified the spread and changes in distribution of non-native oyster, Crassostrea gigas, populations around the coast of Ireland. In total 37 sites were surveyed, in areas which either currently or previously harboured cultivated C. gigas, for the presence and abundance of ‘wild’ C. gigas. Wild populations were identified at 20 sites and at four additional sites C. gigas was observed as recently discarded from aquaculture activity. Five of the invaded sites were identified as being highly suitable for a population expansion based on their current population status. Importantly, we also identified individuals of C. gigas and native European oysters, Ostrea edulis, co-occurring within the same shore at five sites. This is the first record to our knowledge of such co-occurrence within Europe. This evidence of co-existing oyster species raises concerns regarding the potential impact of C. gigas on recovering O. edulis populations. In Ireland, however, C. gigas does not typically spread extensively from introduction points, and although self-containing populations exist, they are currently sustained at a much lower density than those observed in other regions such as the Wadden Sea or French Atlantic coasts. We suggest, therefore, that to protect native oyster populations, C. gigas should be eradicated where co-occurring with O. edulis and recommend continuous monitoring of invaded sites.
Body-focused repetitive behaviours (BFRBs) including trichotillomania, skin picking, and nail biting, are non-functional self-destructive habits, which have a severe negative impact on everyday functioning. Although BFRBs cause distress, they are maintained by both negative (relief) and positive (stimulation) reinforcement. The emotional regulation (ER) model proposes that people with BFRBs have a general deficit in ER and, as a consequence, engage in BFRBs to alleviate affect and reinforce the behaviour. The current study was designed to explore differences in ER between people with BFRBs and controls to identify specific emotions triggering BFRBs. Forty-eight participants (24 BFRB, 24 controls) completed questionnaires measuring Difficulties in Emotional Regulation (DERS), a Triggers Scale and an Affective Regulation Scale (ARS). Significant differences in people with BFRBs and controls were reported principally on the DERS subscales of lack of emotional clarity, difficulties in impulse control, and access to ER strategies. On the ARS, the BFRB group reported overall difficulty ‘snapping out’ of emotions. The majority of BFRBs were reported to be triggered by anxiety (78%), tension (70%), or boredom (52%). The clinical implication is that ER could be beneficially targeted in therapy for BFRBs.
Background: A definitive diagnosis of multiple sclerosis (MS), as distinct from a clinically isolated syndrome, requires one of two conditions: a second clinical attack or particular magnetic resonance imaging (MRI) findings as defined by the McDonald criteria. MRI is also important after a diagnosis is made as a means of monitoring subclinical disease activity. While a standardized protocol for diagnostic and follow-up MRI has been developed by the Consortium of Multiple Sclerosis Centres, acceptance and implementation in Canada have been suboptimal. Methods: To improve diagnosis, monitoring, and management of a clinically isolated syndrome and MS, a Canadian expert panel created consensus recommendations about the appropriate application of the 2010 McDonald criteria in routine practice, strategies to improve adherence to the standardized Consortium of Multiple Sclerosis Centres MRI protocol, and methods for ensuring effective communication among health care practitioners, in particular referring physicians, neurologists, and radiologists. Results: This article presents eight consensus statements developed by the expert panel, along with the rationale underlying the recommendations and commentaries on how to prioritize resource use within the Canadian healthcare system. Conclusions: The expert panel calls on neurologists and radiologists in Canada to incorporate the McDonald criteria, the Consortium of Multiple Sclerosis Centres MRI protocol, and other guidance given in this consensus presentation into their practices. By improving communication and general awareness of best practices for MRI use in MS diagnosis and monitoring, we can improve patient care across Canada by providing timely diagnosis, informed management decisions, and better continuity of care.
Optimal emergent management of traumatic hemorrhagic shock patients requires a better understanding of treatment provided in the prehospital/Emergency Medical Services (EMS) and emergency department (ED) settings.
Described in this research are the initial clinical status, airway management, fluid and blood infusions, and time course of severely-injured hemorrhagic shock patients in the EMS and ED settings from the diaspirin cross-linked hemoglobin (DCLHb) clinical trial.
Data were analyzed from 17 US trauma centers gathered during a randomized, controlled, single-blinded efficacy trial of a hemoglobin solution (DCLHb) as add-on therapy versus standard therapy.
Among the 98 randomized patients, the mean EMS Glasgow Coma Scale (GCS) was 10.6 (SD = 5.0), the mean EMS revised trauma score (RTS) was 6.3 (SD = 1.9), and the mean injury severity score (ISS) was 31 (SD = 17). Upon arrival to the ED, the GCS was 20% lower (7.8 (SD = 5.3) vs 9.7 (SD = 6.3)) and the RTS was 12% lower (5.3 (SD = 2.0) vs 6.0 (SD = 2.1)) than EMS values in blunt trauma patients (P < .001). By ED disposition, 80% of patients (78/98) were intubated. Rapid sequence intubation (RSI) was utilized in 77% (60/78), most often utilizing succinylcholine (65%) and midazolam (50%). The mean crystalloid volume infused was 4.2 L (SD = 3.4 L), 80% of which was infused within the ED. Emergency department blood transfusion occurred in 62% of patients, with an average transfused volume of 1.2 L (SD = 2.0 L). Blunt trauma patients received 2.1 times more total fluids (7.4 L vs 3.5 L, < .001) and 2.4 times more blood (2.4 L vs 1.0 L, P < .001). The mean time of patients taken from injury site to operating room (OR) was 113 minutes (SD = 87 minutes). Twenty-one (30%) of the 70 patients taken to the OR from the ED were sent within 60 minutes of the estimated injury time. Penetrating trauma patients were taken to the OR 52% sooner than blunt trauma patients (72 minutes vs 149 minutes, P < .001).
Both GCS and RTS decreased prior to ED arrival in blunt trauma patients. Intubation was performed using RSI, and crystalloid infusion of three times the estimated blood loss volume (L) and blood transfusion of the estimated blood loss volume (L) were provided in the EMS and ED settings. Surgical intervention for these trauma patients most often occurred more than one hour from the time of injury. Penetrating trauma patients received surgical intervention more rapidly than those with a blunt trauma mechanism.
SloanEP, KoenigsbergM, WeirWB, ClarkJM, O'ConnorR, OlingerM, CydulkaR. Emergency Resuscitation of Patients Enrolled in the US Diaspirin Cross-linked Hemoglobin (DCLHb) Clinical Efficacy Trial. Prehosp Disaster Med. 2015;30(1):1-8.
Objectives: Cognitive stimulation therapy (CST) has been shown to produce improvements in cognition and quality of life which compare favourably with trials of cholinesterase inhibitors. The aim of the present study was to evaluate the efficacy of CST, replicating the methods of Spector et al in the British Journal of Psychiatry in 2003 in a smaller sample using a control group engaged in routine activities.
Methods: Eligible participants (mild to moderate dementia; MMSE range 10-23) were randomised to CST group or control conditions. Pre- and post-intervention testing was undertaken by assessors who were blind to condition. Measures included MMSE, CDR (sum of boxes), ADAS-cog, RAID (anxiety), abbreviated GDS (depression), QoL-AD, and the CAPE Behaviour Rating Scale (BRS). Analysis was by non-parametric statistics. Occupational therapists facilitated two sessions per week for seven weeks in two long-term care facilities and the same programme was run by the activity co-ordinator in a nursing home unit.
Results: Fourteen CST and 13 control participants completed the study. Between group difference scores analysis showed that the CST group improved compared to controls on MMSE (Mann-Whitney U = 32, p = 0.013) and on the QoL-AD which just fell short of significant (U=51.5, p = 0.055). Qualitatively, therapists noted that CST participants demonstrated good interaction and enthusiasm in the group environment, with continuity and carryover between sessions.
Conclusions: Even though the sample sizes are small the current study is consistent with the Spector et al's findings in 2003 of beneficial effects in people with dementia following CST. The programme is recommended as an intervention for people with mild to moderate dementia.
Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.
(Disaster Med Public Health Preparedness. 2011;5:129-137)